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Conflict between parents and children can cause trichotillomania.

Background, Description Of The Condition:

Trichotillomania, TTM, which is classified as an impulse control disorder by DSM-IV, is the compulsive urge to pull out one's own hair leading to noticeable hair loss, distress, and social or functional impairment. It is often chronic and difficult to treat [1].

Trichotillomania is a poorly understood disorder characterized by repetitive hair pulling that leads to noticeable hair loss, distress, and social or functional impairment. [2] The peak age at onset is 12-13 years, and the disorder is often chronic and difficult to treat[3].

Trichotillomania is typically confined to one or two sites. It most frequently affects the scalp but can also involve the eyelashes, eyebrows, pubic hair, body hair, and facial hair [5] Patients tend to be highly secretive about the condition and to regard their behavior as shameful.

Many hair pullers also exhibit additional stereotypic movements, such as nail biting, knuckle cracking, touching or playing with pulled hair, and hair eating [trichophagia] [6,7]. Along with the cosmetic and psychosocial consequences of the disorder, medical complications can occur, including infection, Permanent loss of hair, repetitive stress injury, carpal tunnel syndrome [7], and gastrointestinal obstruction with bezoars as a result of trichophagia [8]. In some cases of trichotillomania, there is an apparent etiological role for stress; hair pulling can be seen as a soothing behavior that is driven by rising tension.

Trichotillomania also shows unexpectedly high overlap with posttraumatic stress disorder [9]. raising the possibility of additional affective contributions. Another school of thought emphasizes hair pulling as addictive or positively reinforcing insofar as it is associated with rising tension beforehand and relief afterward [10]. However, for many patients, hair pulling is undertaken during times of relaxation and may in fact serve a self-stimulatory function [11].

Description Of The Intervention:

A number of different interventions have been used in combating TTM. Cognitive behavioral therapy [CBT] or the selective serotonin reuptake inhibitors [SSRIs] have been administered in the majority of controlled treatment trials for TTM to date [12]. The treatment of choice is called Habit Reversal Training and was developed by Azrin and colleagues. It includes six components: [1] self-monitoring, [2] habit control motivation, [3] awareness training, [4]competing response training, [5] relaxation training, and [6] generalization training. [13].

How The Intervention Might Work:

As mentioned, Habit Reversal Training is a choice treatment for TTM. Most of developers to this disorder pull his or her hair unconsciously, whether it is caused by biological factors or psychological ones. When they were taught to control their impulsive behavior and identify the situations in which they were forced to pull his or her hair, found that they can control impulsive behavior which was cause of baldness. They were taught to use the following ways of coping with their impulsive behavior when they were forced to pull their hair .e.g. when they read a book, grasp the edge of the book, when they sit, take the arm of the chair or sofa, when they walk, put their hands into their pockets till the hair pulling attack goes. Then take a deep breath and relax. Finally, they learned how to perform the six stages one after another. Most of them had the medication therapy as their treatment background but they hadn't gained the favorite result and were unsuccessful. They said that drug didn't have any effects on decreasing their hair pulling attacks and their families like the patients were disappointed with the continuation of medication therapy.

In addition to taking drug, they tried these kinds of things, e.g. shaving their hair, wearing scarfs all the days and night, and also wearing gloves.

Beside all of these behavioral limitations, they were faced with a lot of other restrictions such as not going to the wedding parties, concealing this condition by using make up till they could hide their defect.

All of them were high school or guidance school students. Majority of them removed not only their [head] hair but also their eyebrows and eyelashes. Even one of their mothers expressed that some nights "I woke up and saw that my daughter is sitting next to my pillow and wants to pull my eyebrows, too".

Majority of them belonged to the lower class, but their families were able to meet their needs.

They had some challenges with their families about the quality of their studying at home and efficacy at school, the way of dressing and having relationship with their classmates and friends. Their hair pulling behavior increased when they were usually in struggle with their parents, stressed, watching a movie, alone at their room or when their hair was found by their parents and were quarreled about their behavior.

When their parents were taught to respect their requests and wishes and don't appoint high standards to their success and they themselves were taught to recognize the situation that they were forced to pull their hair, they reached to a good point at controlling their impulsive hair pulling so that they were more successful day by day.

They could recognize their condition by the therapist's help; perform Azrin's six stages by the therapist's guide. After three months of therapy which was performing every week, they were successful in overcoming their impulsive behavior and stop taking the drug. They felt that they have become happier and were satisfied with their self-esteem.

Why It Is Important To Do This Review:

First, a review of pharmacological treatment for TTM concluded that there is no consistent evidence for the efficacy of any pharmacological agent in the treatment of trichotillomania. The second point to be mentioned here is that Habit Reversal Training is the treatment of choice for TTM which is the same with Johan Rosqvist's findings (2005). Third; the parents' conflict with the children has a lot of difficult problems behind, that one of them is trichotillomania. TTM could cause social restrictions, decrease self-esteem and bring negative body image along. Habit Reversal Training treatment is highly efficacious treatment for TTM and doesn't have side effects for patients.


1--Representation an estimate of the relationship between parents and children's conflict and this disorder [TTM].

2--Study of the effectiveness of Habit Reversal Training treatment for this disorder.

3--Identifying an effective treatment.


All of the patients have referred to the private office and mental health centers for the treatment. There were 20 patients who were chosen randomly and their treatment was followed up for one year.

The criteria of diagnosis were based on DSM IV-TR (2000).

Conclusion and Discussion:

TTM is a drastically debilitating condition that has been studied less. Its development could relate to psychosocial biological factors. As the family has a conspicuous role in our success or failure, it will be shown that parent's conflict with their children in their study fields, their interpersonal and parent-child relationship could provoke this disorder and cause its continuation. Respecting children's abilities, having logical and reasonable expectation, solving problem through fundamental and underlying ways and searching for cognitive-behavior therapies are all useful and effective for these kinds of disorders and are recommended.


[1.] Soriano, J.L., R.L. O'Sullivan, L. Baer, K.A. Phillips, R.J. McNally, M.A. Jenike, 1996. Trichotillomania and self-esteem: a survey of 62 female hair pullers. J Clin Psychiatry., 57: 77-82.

[2.] Keuthen, N.J., R.L. O'Sullivan, S. Sprich Buckminster, 1998. Trichotillomania: current issues in conceptualization and treatment. Psychotherapy Psychosomatic, 67: 202-213.

[3.] Diefenbach, G.J., D. Reitman, D.A. Williamson, 2000. Trichotillomania: a challenge to research and practice. Clin Psychol Rev., 20: 289-309.

[4.] Walsh, K.H., C.J. McDougle, 2001. Trichotillomania: presentation, etiology, diagnosis, and therapy. Am J Clin Dermatol, 2: 327-333.

[5.] Cohen, L.J., D.J. Stein, D. Simeon, E. Spadaccini, J. Rosen, B. Aronowitz, E. Hollander, 1995. Clinical profile, co-morbidity and treatment history in 123 hair pullers: a survey study. J Clin Psychiatry, 56: 319-326.

[6.] Du Toit, P.L., J. van Kradenburg, D.J. Niehaus, D.J. Stein, 2001. Characteristics and phenomenology of hair-pulling: an exploration of subtypes. Compr Psychiatry, 42: 247-256.

[7.] Psychiatry, 2005. 162: 242-248.

[8.] Bouwer, C., D.J. Stein, 1998. Trichobezoars in trichotillomania: case report and literature overview. Psychosom Med., 60: 658-660.

[9.] Christenson, G.A., R.L. Pyle, J.E. Mitchell, 1991. Estimated lifetime prevalence of trichotillomania in college students. J Clin Psychiatry, 52: 415-417.

[10.] King, R.A., L. Scahill, L.A. Vitulano, M. Schwab-Stone, K.P. Tercyak Jr, M.A. Riddle, 1995. Childhood trichotillomania: clinical phenomenology, comorbidity, and family genetics. J Am Acad Child Adolesc Psychiatry, 34: 1451-1459.

[11.] Gershuny, B.S., N.J. Keuthen, E.L. Gentes, A.R. Russo, E.C. Emmott, M. Jameson, D.D. Dougherty, R. Loh, M.A. Jenike, 2006. Current posttraumatic stress disorder and history of trauma in trichotillomania. J Clin Psychol, 62: 1521-1529.

[12.] Stein, D.J., S.R. Chamberlain, N. Fineberg, 2006. An A-B-C model of habit disorders: hair-pulling, skin-picking, and other stereotypic conditions. CNS Spectr, 11: 824-827.

[13.] Lara Hoppe *, Jonathan C Ipser Naomi Fineberg, Samuel Chamberlain, Dan J Stein, "Pharmacotherapy for trichotillomania" Editorial Group: Cochrane Depression, Anxiety and Neurosis Group Published Online: 21 JAN 2009 DOI: 10.1002/14651858.CD007662.

[14.] Johan, Rosqvist., 2005. Exposure Treatment for anxiety disorders. Published in Great Britain by Routledge New York. NY 10016.

Abdollah Alizadeh

Islamic Azad University, Eslamshahr Branch" IRAN.

Corresponding Author

Abdollah Alizadeh, Islamic Azad University, Eslamshahr Branch" IRAN.

E-mail: ali alizadeh []
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Title Annotation:Original Article
Author:Alizadeh, Abdollah
Publication:Advances in Environmental Biology
Article Type:Report
Geographic Code:1USA
Date:Jan 1, 2012
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